Download Abdominal wall hernias

Prepared by : Dr. walid elian
• No disease of the human body, belonging to the province of the surgeon,
requires in its treatment a better combination of accurate, anatomical
knowledge with surgical skill than hernia in all its varients.
•
Sir, Astley Paston Cooper , 1804
*The inguinal region must be understood with regard to its three-dimensional
configuration and relation .
*Inguinal canal
*External oblique Aponeurosis .
*Internal oblique Aponeurosis *Transversalis fascia .
*Iliopubic Tract .
* Cooper’s ligament .
*Pre-peritoneal space.
A hernia is the abnormal protrusion of a peritoneal – lined sac
through the musculo aponeurotic covering of the abdomen.
---> weakness of the abdominal wall, congenital or acquired in
origin, result is the inability to contain the visceral contents of
the abdominal cavity within their normal confines
• A patient with groin hernia usually present with the
complaint of :
.Bulge in the inguinal region.
.Minor pain or vague discomfort.
. Ocassionally , parasthesias.
• Masses other than hernias can occur in the inguinal region.
• The inguinal area is examined with the patient standing, the
patient is then examined in supine position.
• Incarcerated hernia can be reduced manually in many
instances.
• Numerous classification systems for groin hernias exist.
A simple and widely used classification system is the
Nyhus classification.
• Approximately 700,000 inguinal herniorrhaphies are
performed in USA each year.
• According to data from national center of health
statistics, the five most common major surgical operation
performed by general surgeons in 1991 were :
• 
• Groin hernia
680,000
• Cholecystectomy
571,000
• ------ of peritoneal adhesion
339,000
• Appendectomy
255,000
• Partial excision of large intestine
220,000
*75% of all hernias occur in the inguinal region .
*50% of hernias are indirect inguinal hernias.
*24% of hernias are direct inguinal hernias.
*10% incisional and ventral hernias.
*3% of femoral
*5%- 10% unusual hernias
• Traditionally divided into two categories:
*Congenital origins.
*Acquired defects.
• Congenital factors are responsible for the majority of groin
hernias.
*Lack of obliteration of the processes vaginalis is the
primary factor leading to the development of an indirect hernia.
*prematurity and low birth weight.
*Congenital abnormalities in the pelvis.
* Congenital deformities or collagen deficiencies .
• Acquired defect :
*Direct hernia attributed to the wear and tear stresses
of life,
eg : straining to urinate or defecate, coughing, heavy lifting.
* Association between cigarette smoking ( groin
hernias has been demonstrated).
* the multifunction process of wound healing provides
many clues to the etiology of groin hernia.
*malnutrition and vit. deficiency
*advance age .
• Occurs through a pace bounded:
*Superiorly by iliopubic tract.
*Inferiorly by cooper’s ligament.
*Laterally by femoral vein.
*Medially by insertion of iliopubic tract into cooper’s ligament.
• On examination:
*A mass below the inguinal ligament.
*More common in females than males.
*Repair -- standard cooper’s ligament (Mc Vay ) repair.
• Vast majority are congenital in origin.
• The umbilical defect closes spontaneously by the age of 2 years .
• Hernias that persist after the age of 5 years are frequently
repaired surgically.
• Umbilical hernias presenting during adulthood are considered
acquired hernias .
• Increased intra-abdominal pressure can develop umbilical
hernias:
-Pregnancy
-Ascitis
-Acute abdominal distention.
Can be repaired by MAYO repair.
• Usually occur as a result of inadequate healing of previous
incision or excessive strain at the site of abdominal wall scar.
• Many of the factors that lead to development of hernias persist
at the time of 2nd repair
• -----> high recurrence :
-Obesity
-Advanced age.
-Malnutrition
-Ascites
- Post operative wound infection
- post operative pulmonary complication
-certain medication ----- to poor wound healing, e.g. steroid
and chemotherapy
• Repair should occur when patient’s underlying medical
condition have been stabilized.
-small hernias -----> simple inerrupted sutures .
-much more common ------> required prosthetic material .
• One in which a viscus forms aportion of the wall of hernial
sac (inguinal )
• Most commonly the viscous involved is segment of bowel
on urinary bladder .
• Primary danger is injury to the viscus during operation
• Essential to the repair is reduction of the viscera into the
peritoneal cavity.
• Epigastric hernia :
-hernias of linea alba occur more above the umbilicus than
below.
-usually small, frequently multiple.
-patient’s complain of painful, pulling sensation at the mid
line up on reclining .
- Repaired with simple suture closure .
• The antimesentric border of the intestine must protrude
into hernia sac but never to the point of involvement of
the entire circumference of the intestine
• Strangulation can occur ----> painful mass , nausea ,
vomiting , abdominal distention.
• Can occur within any type of abdominal wall hernia, but
most common is at the site of femoral hernia.
• Repair according to the location.
• Critical to repair is an adequate evaluation of intestine for
viability
• The presence of Meckel diverticulum as a sole component
of the hernia sac .
• Strangulation of Meckel -----> abscess formation
-------> fistulization .
• Through the fascia along the lateral edge of the rectus
muscle at the space between the semilunal line and the
lateral edge of the rectus.
• Usually successfully repaired at initial operation.
• Hernia though the obturator canal .
• May present with compression of obturator nerve ----->
pain in the medial aspect of the thigh.
• Grynfeltt’s hernia -------> superior lumbar triangle
• Petitis’s hernia ---------> inferior lumbar triangle
• Diffuse lumbar ---------> incisional hernia of kidney
incision
• Through greater sciatic -----------• Extremely unusual- difficult to diagnose.
• Present either by - intestinal obstruction.
- gluteal or infra-gluteal mass .
• Through congenital or acquired defects
• Very unconscious
• In adult patients, complication rates from open inguinal
herniotomy vary from 1%-26%.
• Local and systemic complication have been well
ducumented for many years .
• The rate, magnitude, and nature of complications are
similar whether the laparoscopic or open approach
• Intra operative complications include:
 Injury or transection of spermatic cord structure .
 Vascular injury producing haermorhage .
 Severance or entrapment of nerves.
 Visceral injury (bowel or bladder)
 Systemic such as cardiac arrest and death post operation
– Post operative complications include :
 Wound complication :- infections, haematoma .
 Scrotum & testicle :- hematoma , atrophy, sterility.
 Genito urinary :-retention , UTI
 Pulmonary :- atelectasis , pneumonia .
 DVT
 Recurrence -----> 1%-7% for indirect
4%-10% for direct 5-35% for recurrent